Provider Demographics
NPI:1972564789
Name:FITZGERALD, KEVIN G (MSPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 WEXFORD PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9214
Mailing Address - Country:US
Mailing Address - Phone:724-940-2323
Mailing Address - Fax:724-940-2340
Practice Address - Street 1:1013 WEXFORD PLAZA DR
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9214
Practice Address - Country:US
Practice Address - Phone:724-940-2323
Practice Address - Fax:724-940-2340
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013543L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018254100004Medicaid
PA0018254100004Medicaid